David Levran

Zygote intrafallopian transfer may improve pregnancy rate in patients with repeated failure of implantation

OBJECTIVEnTo evaluate the efficacy of zygote intrafallopian transfer (ZIFT) on implantation rates and pregnancy rates (PRs) in patients with repeated failure of implantation in IVF-ET cycles.nnnDESIGNnA case-control study.nnnPATIENT(S)nCriteria for patient selection included male factor or unexplained infertility, normal uterine cavity, and at least three failures of implantation in IVF-ET cycles in which at least three embryos were placed per transfer. Data on 70 patients who underwent 92 ZIFT cycles are presented. A control group consisted of patients with the same selection criteria who underwent an additional standard IVF-ET cycle during the same time period.nnnINTERVENTION(S)nOvulation induction consisted of down-regulation with GnRH analogue followed by ovarian stimulation with FSH and hMG. Intracytoplasmic sperm injection was performed on the oocytes of all patients with male factor infertility. Zygotes were transferred by laparoscopy into the fallopian tube 24-26 hours after oocyte retrieval.nnnMAIN OUTCOME MEASURE(S)nImplantation rates and PRs in the ZIFT and control groups were compared.nnnRESULT(S)nThe PRs and implantation rates were significantly higher in the ZIFT group than in the control group: 34.2% (24/70) and 8.7% (29/333) versus 17.1% (12/70) and 4.4% (13/289), respectively (P = 0.002 and P = 0.04). The cumulative conception rate for two ZIFT cycles was 59.3%.nnnCONCLUSION(S)nZygote intrafallopian transfer should be considered a beneficial mode of treatment for patients with repeated failure of implantation in IVF and transcervical ET. More prospective randomized studies are needed to support this observation.

Poor outcome with round spermatid injection in azoospermic patients with maturation arrest

OBJECTIVEnTo compare the outcome of intracytoplasmic sperm injection (ICSI) and round spermatid injection (ROSI), both obtained by testicular sperm extraction (TESE), and to compare the results of fresh versus frozen ROSI.nnnDESIGNnRetrospective study.nnnSETTINGnAn IVF unit at a university hospitalPatient(s): Eighteen infertile couples with nonobstructive azoospermia.nnnINTERVENTION(S)nTESE with ROSI or ICSI of mature spermatozoa into metaphase II oocytes was performed. The resulting embryos were transferred to female partners. The spare round spermatids were frozen.nnnMAIN OUTCOME MEASURE(S)nFertilization and cleavage rates, embryo quality, and clinical pregnancy rates.nnnRESULT(S)nSeventeen ROSI cycles and six ICSI cycles were compared. Fertilization rate following ROSI (44.9%) was significantly lower than with ICSI (69%). A significantly higher rate of cleavage arrest occurred following ROSI (40.8%) as compared to ICSI (8.2%). The morphology of embryos resulting from ROSI was significantly poorer. No pregnancies were achieved following ROSI as compared to a 50% clinical pregnancy rate in the ICSI group. The fertilization and cleavage rates following ROSI with fresh versus frozen-thawed spermatids were comparable.nnnCONCLUSION(S)nIn azoospermic patients with maturation arrest at the stage of round spermatids the efficiency of ROSI appears to be extremely poor. The role of ROSI in the treatment of nonobstructive azoospermia should be reevaluated.

Hysteroscopy in a program of in vitro fertilization

Two hundred twenty-four women underwent hysteroscopic evaluation without anesthesia after at least two failed attempts of in vitro fertilization and embryo transfer. One hundred fifty-three (68%) women were diagnosed as having mechanical infertility, and abnormal hysteroscopic findings were observed in 32 (21%). Forty-one women were diagnosed as having unexplained infer-tility (18%) and six (15%) had abnormal findings with hysteroscopy. Of the 30 couples who entered the in vitro fertilization regimen program because of male infertility, 4 (13%) had abnormal findings. The overall rate of abnormal findings was 19%; cervical canal and intrauterine abnormalities were found in 10 and 32 patients, respectively. Ten patients were treated during hysteroscopic evaluation procedure, and four patients subsequently underwent operative hysteroscopy under general anesthesia. We suggest that diagnostic hysteroscopy should be a routine procedure before in vitro fertilization and embryo transfer therapy.

Zygote intrafallopian transfer among patients with repeated implantation failure

To summarize the experience of a single center with laparoscopic zygote intrafallopian transfer (ZIFT) performed exclusively among patients with high‐order repeated implantation failure (RIF) following in vitro fertilization‐embryo transfer (IVF‐ET).

Possible risk for cancer among children born following assisted reproductive technology in Israel

Among children conceived by assisted reproductive technology (ART), increased risk of adverse birth outcomes has been observed, including multiple births, preterm births, and congenital malformations. Regarding cancer among ART‐conceived children, findings are discrepant.

Unsuccessful methotrexate treatment of a tubal pregnancy with a live embryo

Two cases with unsuccessful local and systemic methotrexate (MTX) therapy of tubal pregnancy with fetal heart rate activity are reported. The three modes of therapy, the first with local potassium chloride solution injection, the second with local MTX injection, and the third with systemic MTX injection, failed in the resolution of viable ectopic pregnancy. Therapy of MTX in cases of tubal pregnancy with demonstrable fetal heart rate beats, should be reconsidered.

Administration of DHEA augments progesterone production in a woman with low ovarian reserve being transplanted with cryopreserved ovarian tissue

We read with interest the paper of Strauss et al. [1] describing a patient that following transplantation of ovarian tissue for fertility preservation, exhibited increased circulating progesterone concentrations during DHEA supplementation. Since the patient was menopausal at the time of transplantation, and had only a small fraction of ovarian tissue transplanted, the authots attributed the increase in progesterone production to an augmented adrenal synthesis of progesterone. n nWe have previousely described [2] a similar phenomenon in patients with diminished ovarian reserve (DOR) undergoing controlled ovarian stimulation (COS) prior to IVF. In a case control study, we compared progesterone levels during the follicular phase in IVF cycles before and during DHEA supplementation in 15 women with DOR who received 75xa0mg of DHEA daily. Progesterone levels on stimulation day 5 (ng/mL) (0.58u2009±u20090.29 vs. 1.54u2009±u20090.49; pu2009<u20090.0001); and on the day of hCG administration (0.75u2009±u20090.31 vs. 1.87u2009±u20090.49; pu2009<u20090.0001) were significantly higher during DHEA treatment. The number of retrieved and fertilized oocytes was similar in both groups. Five patients (33xa0%) had a clinical pregnancy following DHEA supplementation, of whom 2 had spontaneous abortions and 3 delivered healthy newborns. We concluded that DHEA administration during IVF cycles in women with DOR causes a significant elevation of progesterone levels without an apparent deleterious effect on cycle outcome. n nThe mechanism for the observed increase in progesterone levels during DHEA supplementation remains unknown. Altered adrenal and/or ovarian function as well as alterations in steroidogenic pathways that favor progesterone production could all be implicated. In addition, the possibility of cross reaction between DHEA and progesterone in currently available commercial assays should also be explored. More information and further studies are needed in order to increase our understanding of the effects of DHEA supplementation on reproductive function and outcome.

A previous caesarean section is not a risk factor for tubal abnormalities in the infertile population

Abstract In this retrospective cohort study of 1716 cases of women undergoing infertility treatment between the years 1999–2012, we aimed to identify whether parturients with a previous surgical history are at a higher risk for tubal abnormalities as determined by hysterosalpingography (HSG) in this infertile population. Amongst the study population, tubal obstruction was identified on HSG in 15.8% of patients with no past history of an abdominal surgery and 16.3% of patients with a previous caesarean section (CS) delivery. These rates were significantly lower than those for women with a previous gynaecological surgery (34.7%) or abdominal surgery (27%) (pu2009<u2009.001 for all comparisons). Our results suggest that past history of CS poses no additional risk for tubal abnormality within the infertile population, whereas a history of other abdominal or gynaecological surgical procedures doubles this risk. Impact Statement What is already known on this subject? While numerous risk factors for tubal factor infertility have been established, to date, the relation between previous abdominal surgeries and the risk for tubal factor infertility remains inconclusive. What the results of this study add? In this study, we aimed to evaluate the correlation between previous CS history and the risk for having tubal factor infertility. Our results demonstrated that previous caesarean section delivery does not increase the risk for tubal factor infertility in the infertile population, whereas history of other abdominal or gynaecological surgical procedures doubles this risk. What the implications are of these findings for clinical practice and/or further research? Further research is needed for further evaluation of this association and its clinical implications.

The relative success of gonadotropin-releasing hormone analogue, clomiphene citrate, and gonadotropin in 1,099 cycles of in vitro fertilization

OBJECTIVESnTo evaluate the effectiveness of and analyze the factors influencing the outcome of three ovarian stimulation protocols used during in vitro fertilization (IVF) in a large population.nnnDESIGNnRetrospective file review.nnnSETTINGnIn vitro fertilization program in one center during the years 1985 to 1990. PATIENTS AND PROTOCOLS: Three hundred forty-one patients received clomiphene citrate (CC) and human menopausal gonadotropin (hMG), 365 received hMG alone, and 393 received gonadotropin-releasing hormone analogue (GnRH-a) for pituitary suppression followed by hMG stimulation.nnnMAIN OUTCOME MEASUREnRates of cancellation, total pregnancies, and ongoing pregnancies, with breakdown by age of patients.nnnRESULTSnThe cancellation rate because of early luteinization following GnRH-a/hMG was significantly reduced compared with the other two protocols: 3.6% versus 9.4% and 13.7% for CC/hMG and hMG, respectively. However, in women over 40 years of age, GnRH-a/hMG resulted in the highest rate of poor ovarian response. Significantly more oocytes were retrieved, fertilized, and cleaved after the use of GnRH-a/hMG compared with the other two protocols. Despite this, clinical pregnancy rate (PR) was the highest with CC/hMG compared with GnRH-a/hMG and hMG:31.4% versus 16.9% and 15.7%, respectively. Ongoing PRs were 20.5%, 9.7%, and 11.6%, respectively.nnnCONCLUSIONSnAlthough the use of GnRH-a for pituitary suppression before ovarian stimulation for IVF reduced the cancellation rate and increased the number of retrieved oocytes, it was not found to result in higher PRs than those achieved by stimulation with CC/hMG. This suggests that treatment by GnRH-a/hMG should be reserved mainly for the prevention of early luteinization.

Failure of oocyte retrieval during in vitro fertilization: A sporadic event rather than a syndrome

Failure to retrieve oocytes during in vitro fertilization (IVF) treatment was recently referred to as the empty follicle syndrome. Data on the possible repetitiveness of this during previous or subsequent IVF attempts is lacking, which limits the understanding of its significance to the involved patients. Of 26 patients who had cycles during which no oocytes were retrieved, 10 were pregnant in the past and 20 had at least one other IVF cycle that yielded oocytes. There was no difference in the frequency of any stimulation protocol among the failure cycles compared with the successful ones. Hormonal response pattern and the number of large follicles observed sonographically did not differ between the two occasions. Fertilization occurred in 70% of the successful cycles and two biochemical pregnancies were recorded. In 13 patients, at least one cycle was canceled because of poor ovarian response, but 9 of these 13 had at least one other successful cycle. We conclude that the so-called empty follicle syndrome cannot be predicted by the pattern of ovarian response and does not predict a reduced fertility potential in future cycles.